Provider Demographics
NPI:1578052239
Name:JEFFERSON, NICOLE L (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 20TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-893-2639
Mailing Address - Fax:701-893-2638
Practice Address - Street 1:3242 20TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-893-2639
Practice Address - Fax:701-893-2638
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20712251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic